CMS Inspection Results for WRANGELL MEDICAL CENTER LTC

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 11/06/2008 Health Survey for WRANGELL MEDICAL CENTER LTC

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Immediate jeopardy to resident health or safety
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm

 

• 11/05/2008 Fire Safety Survey for WRANGELL MEDICAL CENTER LTC

Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm

 

• 12/12/2007 Health Survey for WRANGELL MEDICAL CENTER LTC

Quality Care
Deficiency	Scope	Level of Harm
Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Widespread	Minimal harm or potential for actual harm
Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm

 

• 12/12/2007 Fire Safety Survey for WRANGELL MEDICAL CENTER LTC

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm

 

• 04/17/2007 Fire Safety Survey for WRANGELL MEDICAL CENTER LTC

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
properly maintained smoke detectors.	Widespread	Potential for minimal harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Widespread	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm

 

• 01/25/2007 Health Survey for WRANGELL MEDICAL CENTER LTC

Administration
Deficiency	Scope	Level of Harm
Have a detailed, written plan for disasters and emergencies.	Widespread	Potential for minimal harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Widespread	Potential for minimal harm
Resident Rights
Deficiency	Scope	Level of Harm
Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm